Purpose: Cryptococcal fungal infections can affect both the central nervous system (CNS) and pulmonary manifestations, especially in immunocompromised patients. Cryptococcal meningitis, caused by the encapsulated yeast Cryptococcus neoformans, is known most notably as an opportunistic infection in patients with human immunodeficiency virus (HIV), but can occur in other conditions associated with an immunocompromised state (sucg as alcoholism, diabetes, malignancy, etc.). Case report: A

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... ld diabetic man presented with fever for 4 days. There were no consciousness change. He was admitted because of pneumonia. His blood culture grew Cryptococcus neoformans; therefore fluconazole was added. However, acute respiratory failure occurred. His was intubated and then he was transferred to an intensive care unit. Broad-spectrum antibiotic with piperacillin-tazobactam were added in addition to fluconazole for fungemia. Spine MRI was arranged for unexplained lower limbs weakness and the result showed multiple lesions at vertebral bodies and spinal processes, suggesting myelopathy. Lumbar puncture revealed an elevated CSF Cryptococcus antigen titer of 1: 16. Despite fluconazole therapy, serial blood culture still grew C. neoformans. We replaced fluconazole with amphotericin B and flucytosine as standard induction therapy. Cardiac echo gram was done, but no vegetation was found. Anti-HIV test was negative. As difficult weaning of ventilator use, bronchoscopy was performed, which found multiple nodular lesions in the whole trachea-bronchi. However, biopsy of bronchus and sputum cytology did not find Cryptococcal organism. After complete the induction therapy for cryptococcus, he was transferred to a respiratory care ward for further management. Follow-up blood culture became negative. Consolidation and maintenance therapy for cryptococcal infection was in progress. Conclusions: We report a non-HIV case of complex CNS infections by C. neoformans, involving meninges, spine, spinal cord and probably endo-tracheobronchus, albeit Cryptococcus was not found in the respiratory specimens. The difficult-to-treat infection caused prolonged weaning process.